Inspection·March 13, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few staff at meals, needed adaptive equipment at meals, and needed extra drinks to meet fluid needs. and. Interventions included document fluid/food intakes, provide an altered fluid consistency as ordered, no water pitcher at bedside and a mechanically altered diet as ordered. The care plan did not mention Resident #57 was assisting with mixing and providing Resident #51 with thickened liquids. Review of an untitled facility document dated 01/17/24 and authored by Assistant Director of Nursing (ADON) #301, revealed she educated Resident #57 on thickening liquids for Resident #51 and Resident #57 returned the demonstration which was done at the request of Resident #51's Power of Attorney. Resident #57 was able to thicken fluids as required and Resident #57 was aware that the facility did not encourage this. Resident #57 was also educated on the risk and sign symptoms of choking if thickened fluids were not thickened properly. Review of a facility's SRI (tracking number 243523) created on 01/19/24 at 7:45 P.M. revealed the staff observed Resident #57 in Resident #51's room and created the SRI for an allegation of abuse. During the interviews, Resident #57 stated he was in Resident #51's room feeding the resident a magic cup. The facility indicated this was a normal act since Resident #51's family encouraged Resident #57 to engage with their son and the SRI for abuse was unsubstantiated. Interview with State Tested Nurse Aide (STNA) #304 on 03/06/24 at 10:04 A.M., revealed Resident #57 would mix up Resident #51's thickened liquids in Resident #51's room then serve the liquids to the resident. STNA #304 stated she was told by management that Resident #57 had been approved and care planned to provide the thickened liquids to Resident #51. STNA #304 indicated she never saw the careplan for Resident #51 and only went off of what the management team told her. STNA #304 stated she did not think it was safe for Resident # 57 to mix and provide thickened liquids to Resident #51 Interview with STNA #305 on 03/06/24 at 10:06 A.M., revealed Resident #57 goes into Resident #51's room and mixes up his thickened liquids then administers it to Resident #51. STNA #305 stated she did not think it was safe for Resident #57 to mix up and provide Resident #51 with thickened liquids. Observation of Resident #51's room at the same time with STNA #305, revealed a large tub of thickener and a cup of what appeared to be a very thin liquids at the bedside. Interview with Resident #57 on 03/06/24 at 10:46 A.M., revealed he regularly provided Resident #51 with thickened liquids that he mixed. Resident #57 stated Resident #51's family and the facility were aware of this and were ok with it. Resident #57 stated the nursing staff provided him with education and training on how to mix and provide Resident #51 with the thickened liquids. Resident #57 stated he is aware that different types of liquids require a different mixture of the thickener. Resident #57 stated he was also provided with education on what steps to take if Resident #51 were to choke while Resident #57 provided Resident #51 with the fluids. Interview with the Assisted Director of Nursing (ADON) #301 on 03/06/24 at 12:07 P.M. verified Resident #57 provided thickened liquids to Resident #51. ADON #301 reported she provided education and completed a skills competency on 01/17/24 with Resident #57 so he could mix and provide thickened liquids to Resident #51 properly. ADON #301 stated Resident #51's family encouraged Resident #57 to provide Resident #51 with additional liquids between meals when the staff were not available so Resident #51 could stay hydrated. ADON #301 stated she felt Resident # 57 was going to provide Resident #51 with the thickened liquids despite the facility being against it and therefore felt Resident #57 should provide the liquids to Resident #51 in a safe manner. Interview with Registered Dietician (RD) #300 and ADON #301 on 03/06/24 at 12:07 P.M. confirmed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/13/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Majestic Care of Fairfield LLC 5200 Camelot Drive Fairfield, OH 45014 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #51 was ordered to receive a puree diet with nectar thickened liquids. ADON #301 confirmed the facility did not have any documentation of the physician being aware or having an active care plan in place related to Resident #57 providing thickened liquids to Resident #51. Observation of Resident #51's room with RD #300 on 03/06/24 at 12:10 P.M. revealed a large container of thickener on the table next to Resident #51's bed. RD #300 stated the thickener must have been brought in by the family. Interview with ADON #300 on 03/06/24 at 3:27 P.M. indicated the facility had no risk agreement on file for Resident #57 providing thickened liquids to Resident #51. ADON #300 indicated she had a complaint from Resident #51's father about the resident not receiving showers when she learned of Resident #57 mixing and given Resident #51 thickened liquids. Interview with Director of Nursing (DON) on 03/06/24 at 3:35 P.M., revealed the facility was aware of Resident #57 mixing and providing thickened liquids to Resident #51. The DON stated the facility only educated Resident #57 on 01/17/24 in the event Resident #57 provided thickened liquids to Resident #51 without staff's knowledge. The DON stated this was recently discovered while investigating a complaint from the resident's father about showers not being done. When the DON was questioned about the notes of Resident #57 providing the thickened liquids dating back to January 2023, the DON indicated she was not aware of that since she was not employed then. Review of the facility policy titled, Thickened Liquids, dated October 2018, revealed liquids that require consistency medication will either be purchased pre-thickened and/or be thickened with commercial thickener by Nutrition and Dining Services Care Team Staff or community Speech Therapists. The policy stated thickened liquids will be available in nourishment pantries for offering of liquids at times of resident request as well as medication pass. This deficiency represents non-compliance investigated under Master Complaint Number OH00151172. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365396 If continuation sheet Page 3 of 3